Health Inequity and Disaster Vulnerability

"Equity is the journey. Equality is the destination"

From Keim, M.  Emergency Health: Principles and Practice. American Public Health Association Press, Washington, DC. May 2023.  

Health equity is the absence of unfair, avoidable, or remediable differences in health status among population groups defined socially, economically, demographically, or geographically. Like health, health inequity is also determined by a full range of personal AND ecosocial factors. Simply put, health equity is attaining the highest level of health for all people. 

In the case of disasters, huge differences exist between groups of people who systematically experience more significant obstacles to health based on their race, ethnicity, religion, socioeconomic status, gender, age, disability, sexual orientation, gender identity, or geographic location compared with the collective majority. 

Health equity recognizes that in addition to the social determinants that create health, there are also significant ecosocial obstacles to health and well-being. These obstacles create health disparities, "differences in health status that are closely linked with social, economic or environmental disadvantage."

It is among these distal determinants of health (DoH) that the causes disaster-related injuries and illness first originate. Seated within the context of societal beliefs and attitudes are the undercurrents of public sentiment that create, sustain, tolerate, or ignore public opinion and disaster policy.

Obstacles to health are sustained and exacerbated by misinformed public opinion and misdirected public policies that tend to overemphasize the biological and physical factors while underemphasizing the social, cultural, economic, environmental, and political determinants of health.

Society is too willing to "medicalize" social needs and criminalize social deficiencies.

The resultant system tends to spend a lot to provide reactive medical services instead of making an investment in health. In addition to addressing social needs with a patchwork of disaster medical care, society tends to stigmatize those in need.

These persons have become popularly referred to as "vulnerable populations." The root of the word vulnerability comes from "vulnus," the Latin for wound. Using a medical model, this "wound" is treated as damage or losses sustained by the individual. There is an implied sense that these individuals are wounded and somehow less than the whole. So-called vulnerable populations are then encouraged to somehow become resilient in a way that does not sddress the distal ecosocial causes of disaster-related disease - that are created mainly by persons other than the disaster victim.  

This model assumes that health differences (like vulnerability) are self-generated and individual rather than a complex mix of ecosocial determinants over time. While this may appear more suitable for the disposition of the crisis, this medical approach does not address the social, cultural, or economic and political determinants of the cause. By comparison, an ecosocial model recognizes that vulnerability is not merely an individual attribute but rather a complex collection of conditions created over time.

Health is determined by a complex set of factors that include the proximate cause of hazardous exposures and the more distal upstream DoH that occur at the level of the individual, family, community, or society.

Characteristics of the individual (e.g., demographic, psychological, physiological) often serve as both risk and protective factors for determining the likelihood of illness and disease. These upstream factors include a range of personal characteristics that create disaster-related exposures, and thus resultant disease, more likely to occur.

In addition to personal factors, an individual’s family, community, and societal context encompass crucial DoH. They include upstream factors such as social, technological, economic, environmental, cultural, and political influences that make exposures (and resultant disease) more likely to occur. 

Societal beliefs and attitudes provide a broad context for policies that either increase or decrease the risk of disaster-related exposure. These beliefs may be related to diversity, equity, environmental justice, and human rights and under the influence of economics, climate, interpersonal conflicts, and risk perceptions.

This difference in terminology is not insignificant. The medical approach does more than narrow the range of opportunity. Populations treated as medically "wounded" after a disaster are more likely to become patients in a health care system and are more likely to undergo medical interventions (regardless of effectiveness).

Disaster-related health inequities have been well documented according to race and ethnicity, class and socioeconomic status, sexual orientation and gender identity, immigration and documentation status, or residence. However, labeling some groups as vulnerable may also lead group members to internalize stereotypes and may thus be unintentionally detrimental to health equity.

Perhaps Grumbach's definition of a vulnerable population as "wounded by social forces placing them at a disadvantage for their health" is a more accurate representation of this human condition resulting from ecosocial, not merely biological or behavioral, determinants.

In this sense, health equity recognizes the influences of social, technological, economic, environmental, political, and cultural health determinants that either decrease or increase the likelihood of disaster-related disease over time.